Appendix 51

PURCHASE REQUEST
DOH - Regional Office 3
Agency

Department: Regional Office 3 PR No.: _____________ Date: May 17, 2016

Section: LHSD-IHCP SAI No.: ____________ Date: _____________

Stock No. Unit Item Description Quantity Unit Cost Total Cost
pax Meal and Snack (P350 X 1,490 pax) 10 sites 1,490 350 521,500
********
Distribution of Budget
Bataan (P350 X 125 pax)
Bulacan (P350 X 300 pax)
Malolos City (P350 X 130 pax)
Meycauayan City (P350 X 130 pax)
Cabanatuan City (P350 X 130 pax)
San Jose City (P350 X 130 pax)
Pampanga (P350 X 155 pax)
Angeles City (P350 X 130 pax)
Tarlac PHO (P350 X 130 pax)
Tarlac City (P350 X 130 pax)
********

Chargeable against IHCP SAA from DPCB OID Budget 2016

Not to exceed the amount of PhP521,500
SAA no. 2016-04-0625 521,500
Purpose: Partner's Forum for Soil Transmitted Helminth Control Program
Date: June 1 to July 20, 2016
Requested by: Approved by:

Signature:
Printed Name: LAILANI P. MANGULABNAN,MD,MPH LEONITA P. GORGOLON, MD, MHA, MCHM, CEO VI
Designation: Chief-LHSD Director IV

DOH-CHD3-MSSD-WI-02-00 Form4 Rev.0

 Appendix 51
PURCHASE REQUEST
DOH - Regional Office 3
Agency

Department: Regional Office 3 PR No.: _____________ Date: May 17, 2016

Section: LHSD-IHCP SAI No.: ____________ Date: _____________

Stock No. Unit Item Description Quantity Unit Cost Total Cost
pax Meal and snack (P350 X 1,300 pax) 5 sites 1,300 350 455,000
********
Distribution of Budget
City of San Fernando (P350 X 100 pax)
Mabalacat City (P350 X 100 pax)
Tarlac PHO (P350 X 100 pax)
Zambales (P350 X 500 pax)
Olongapo City (P350 X 500 pax)
********

Chargeable against IHCP SAA from DPCB OID Budget 2016

Not to exceed the amount of PhP455,000
455,000
Purpose: Orientation for priority sectors for HSCMDA(parents and health point persons/field health staff)
Date: June 2016

Requested by: Approved by:

Signature:
Printed Name: LAILANI P. MANGULABNAN,MD,MPH LEONITA P. GORGOLON, MD, MHA, MCHM, CEO VI
Designation: Chief-LHSD Director IV

DOH-CHD3-MSSD-WI-02-00 Form4 Rev.0

 Appendix 51
PURCHASE REQUEST
DOH - Regional Office 3
Agency

Department: Regional Office 3 PR No.: _____________ Date: May 18, 2016

Section: LHSD-IHCP SAI No.: ____________ Date: _____________

Stock No. Unit Item Description Quantity Unit Cost Total Cost
pcs 3 ft. X 4 ft. Tarpaulin 933 300 279,900
*******

Chargeable against GAD 2016

Not to exceed the amount of PhP279,900

279,900
Purpose: To be used for reproduction of Tarpaulins for Infectious Diseases (Deworming)
Date: June 20-22, 2016

Requested by: Approved by:

Signature:
Printed Name: LAILANI P. MANGULABNAN,MD,MPH LEONITA P. GORGOLON, MD, MHA, MCHM, CEO VI
Designation: Chief-LHSD Director IV

DOH-CHD3-MSSD-WI-02-00 Form4 Rev.0

 Appendix 51
PURCHASE REQUEST
DOH - Regional Office 3
Agency

Department: Regional Office 3 PR No.: _____________ Date: May 18, 2016

Section: LHSD-IHCP SAI No.: ____________ Date: _____________

Stock No. Unit Item Description Quantity Unit Cost Total Cost
pax Meals and Accomodation (P1200 X 140 pax X 2D) 140 1,200 336,000
********
Title: Regional Forum on Integration of Deworming Program
with Conditional Cash Transfer Assistance
Venue: To be determined
Date: June 13-14, 2016

********

Chargeable against IHCP Regular GAA 2016

Not to exceed the amount of PhP259,373
Chargeable against IHCP SAA DPCB OID 2016 (SA # 2016-04-0625)
Not to exceed the amount of PhP76,627

336,000
Purpose: Regional Forum on Integration of Deworming Program with Conditional Cash Transfer Assistance

Requested by: Approved by:

Signature:
Printed Name: LAILANI P. MANGULABNAN,MD,MPH LEONITA P. GORGOLON, MD, MHA, MCHM, CEO VI
Designation: Chief-LHSD Director IV

DOH-CHD3-MSSD-WI-02-00 Form4 Rev.0

 Appendix 51
PURCHASE REQUEST
DOH - Regional Office 3
Agency

Department: Regional Office 3 PR No.: _____________ Date: May 17, 2016

Section: LHSD-IHCP SAI No.: ____________ Date: _____________

Stock No. Unit Item Description Quantity Unit Cost Total Cost
pax Meal and Snacks (P600 X 60 pax) 7 batches 420 600 252,000
********
Title: Enhancing Collaborative Approach on Public-Private
Partnership for Soil-Transmitted Helminth Control Program
Venue: To be determined
Date: June 2016

********

Chargeable against IHCP SAA OID Budget from DBM 2016

Not to exceed the amount of PhP252,000

252,000
Purpose: Enhancing Collaborative Approach on Public-Private Partnership for Soil-Transmitted Helminth Control Program

Requested by: Approved by:

Signature:
Printed Name: LAILANI P. MANGULABNAN,MD,MPH LEONITA P. GORGOLON, MD, MHA, MCHM, CEO VI
Designation: Chief-LHSD Director IV

DOH-CHD3-MSSD-WI-02-00 Form4 Rev.0

 Appendix 51
PURCHASE REQUEST
DOH - Regional Office 3
Agency

Department: Regional Office 3 PR No.: _____________ Date: June 27, 2016

Section: LHSD-LCP SAI No.: ____________ Date: _____________

Stock No. Unit Item Description Quantity Unit Cost Total Cost
pcs Clobetasol Cream 5g/tube 400 300 120,000
Mupirocin Ointment 5g/tube 320 250 80,000
Miconozole Ointment 5g/tube 250 400 100,000
********

Chargeable against LCP SAA from DPCB EOD Budget 2016

Not to exceed the amount of PhP300,000
SAA #: 2016-04-0567

300,000
Purpose: To be used for the procurement of support medicines for Leprosy Control Program
Date: August 2016

Requested by: Approved by:

Signature:
Printed Name: LAILANI P. MANGULABNAN,MD,MPH LEONITA P. GORGOLON, MD, MHA, MCHM, CEO VI
Designation: Chief-LHSD Director IV

DOH-CHD3-MSSD-WI-02-00 Form4 Rev.0

 Appendix 51
PURCHASE REQUEST
DOH - Central Luzon Center for Health Development
MEGA-DRUG ABUSE TREATMENT & REHABILITATION CENTER
Fort Magsaysay, Palayan City

Department: Mega-DATRC PR No.: ____________ Date: August 8, 2019

Section: Supply Section SAI No.: ____________Date: _____________

Stock No. Unit Item Description Quantity Unit Cost Total Cost

Perform Preventive Maintenance Service 8,640.00 8,640.00

Engine Oil Fully Synthetic 4,980.00 4,980.00
Oil Filter 968.00 968.00
Air Fiiter 3,000.00 3,000.00
Brake Cleaner 380.00 380.00
Windshield Washer Cleaner 200.00 200.00
Oil Penetrant 480.00 480.00
Aircon Cleaner 730.00 730.00
Engine Flush 650.00 650.00
Complete Wash 900.00 900.00
Miscellaneous 320.00 320.00
Pollen Filter 2,408.00 2,408.00
Fuel Filter 4,830.00 4,830.00
Timing Belt 4,500.00 4,500.00
Timing Belt Tensioner 2,775.00 2,775.00
Timing Belt Bolt 27.00 27.00
Drive Belt 1,854.00 1,854.00
Drive Belt Tensioner 6,690.00 6,690.00
Drive Belt Idler (small) 3,750.00 3,750.00
Drive Belt Idler (big) 3,665.00 3,665.00
Drive Belt Idler (Pulley) 1,493.00 1,493.00
Water Pump 4,802.00 4,802.00
Engine Coo;ant 1,630.00 1,630.00
Drain Plug Washer 147.00 147.00

Charge to Mega-DATRC Funds 59,819.00

Purpose: For the use of RP vehicle Chevrolet Colorado (WC8324)

Requested by: Approved by:

Signature:
Printed Name: NELSON J. DANCEL, MD, FPAMS CESAR C. CASSION, MD, MPH, CESO IV
Designation: OIC- Chief of Hospital Director IV
DOH-CHD3-RD/ARD-W1-04 Form4 Rev.0